Clinical Reviewer, Nurse – Medical Oncology

📋 Description

• The Clinical Review Nurse is tasked with conducting precertification and prior approvals.

• Responsibilities are carried out within the RN scope of practice, guided by the Medical Director, utilizing independent nursing judgment, physician-developed medical policies, and clinical decision-making criteria.

• The Clinical Review Nurse acts as a patient advocate, facilitating care throughout the continuum and collaborating with the healthcare delivery team to ensure high-quality, cost-effective care.

• Conducts pre-certification utilization reviews for Oncology treatment requests, specifically chemotherapy.

• Assesses the medical necessity and appropriateness of services based on clinical review criteria.

• Diligently documents all review rationales and decisions made.

• Correctly identifies and refers cases that fail to meet established clinical criteria to the Medical Director.

• Recognizes and refers quality concerns to UM Leadership as appropriate.

• Works in partnership with physicians and other providers to ensure the continuation of services throughout the healthcare continuum.

• Executes precise data entry tasks.

• Relays necessary information to other staff members as needed.

• Engages in continuing education opportunities.

• Availability during some weekends and holidays may be necessary.

• Executes additional duties as assigned.

⛳️ Requirements

• Must be a Registered Nurse with a current, unrestricted license in your state of residence.

• Requires an Associate’s or Bachelor's Degree in Nursing.

• A minimum of three years of direct clinical patient care experience is required (in acute, inpatient, or critical care settings); direct Oncology experience is strongly preferred.

• Proficiency in computer skills, particularly with the MS Office Suite, is essential.

• Excellent interpersonal, oral, and written communication skills are necessary.

• Must be available for a 9 AM-6 PM shift, Monday through Friday, with a rotation for weekends and holidays.

🏝️ Benefits

• Health insurance coverage.

• Comprehensive benefits available to qualifying employees.